Checklist: Temporary Certification as an Alcohol and Drug Counselor Page 1 of 5

This document is to only be used as a guide, not an interpretation of the law. To read the law in its entirety see Kentucky Revised Statutes KRS 309.080 to KRS 309.089 and Kentucky Administrative Regulations 201 KAR 35:010 to 201 KAR 35:090.

KENTUCKY BOARD OF ALCOHOL AND DRUG COUNSELORS

P.O. Box 1360, Frankfort, Kentucky 40602 ~ 911 Leawood Drive, Frankfort, Kentucky 40601 Phone (502) 782-8814 ~ http://adc.ky.gov

TEMPORARY CERTIFICATION AS AN ALCOHOL AND DRUG COUNSELOR (TCADC)

APPLICATION INFORMATION & CHECKLIST

Description: Temporary CADC Applicants have a Baccalaureate degree (in any field) or higher and need to obtain the

work experience, supervision, and training needed to become a CADC.

Or

Temporary CADC Applicants with a qualifying Master’s Degree could be pursuing Licensure (LCADC) instead of

Certification (CADC) and need to obtain the work experience, supervision, and training needed to become an LCADC. It

is not a requirement that a Temporary CADC must apply next for the CADC. One may be a Temporary CADC and then

apply directly for the LCADC when ready.

1. Eighteen (18) years of age or older.

2. Section 1 of application completed.

3. Section 2 completed – describing education attainment of at least a Bachelor’s degree.

4. Request an official transcript conferring your highest degree be sent from the registrar of the

institution directly to the Board address listed at the bottom of this page (issued to student and

copies of transcripts are not acceptable, let the Board Administrator know if your last name was

different at the time of your degree).

5. Section 3 completed – list your relevant work experience obtained thus far, as well as where you

expect to obtain your relevant work/supervision experience.

6. Sign the Affidavit at bottom of page 2

7. Supervisory Agreement – Completed and signed by you and your Board Approved Supervisor

8. Check or money order made payable to the Kentucky State Treasurer (DO NOT SEND CASH)

Temporary Certification as an Alcohol and Drug Counselor Application Fee $50.00

(Application fee does not need to be paid again when submitting the full CADC application)

The completed application may be submitted to the Kentucky Board of Alcohol & Drug Counselors by mail to:

P.O. Box 1360, Frankfort, KY 40602 or delivered/special delivery/signature required to 911 Leawood Drive,

Frankfort, KY 40601.

Materials must be received by our office at least 10 DAYS PRIOR to the next scheduled Board Meeting to ensure

placement on the agenda. If this deadline is not met, your application will most likely be added to the next month’s

agenda for review. Board meeting dates are on our website http://adc.ky.gov under “Quick Links.”

Checklist: Temporary Certification as an Alcohol and Drug Counselor Page 2 of 5

This document is to only be used as a guide, not an interpretation of the law. To read the law in its entirety see Kentucky Revised Statutes KRS 309.080 to KRS 309.089 and Kentucky Administrative Regulations 201 KAR 35:010 to 201 KAR 35:090.

Important Information

Incomplete applications will not be reviewed and you will not be notified when your application arrives. Your

check being cashed does not mean your application has been reviewed. It is the applicant’s responsibility

to make certain that all materials have been received by the Board administrator. You may contact the

office to check on the status of your application. Email is best: Kelly.Walls@ky.gov

For those working to obtain the CADC: Supervision hours accrued prior to August 24th, 2015 must be with a

Kentucky CADC in good standing with the Board for at least 2 years of post-certification experience at the time of

supervision. Any supervision occurring after August 24th, 2015, must be with a Board-approved CADC or LCADC

supervisor of record and Board-approved supervisory contract as tied to the supervisee’s active and issued Temporary

CADC. One must be an approved and active TCADC, approved by the Board, prior to starting supervision and engaging

in the practice of alcohol and drug counseling.

For those working to obtain the LCADC: Effective February 5th, 2016, 201 KAR 35:070 Amendment Section 1 (6)

became law. Supervision hours completed prior to February 5th, 2016 can count toward the LCADC supervision

requirement as long as the supervisor was a current Kentucky LCADC, or a current CADC in good standing with at least

2 or more years of post-certification experience at the time of supervision. Any supervision occurring after February 5th,

2016, must be with a Board-approved LCADC supervisor of record and Board-approved supervisory contract as tied to

the supervisee’s active and issued Temporary CADC in order to count towards the LCADC supervision requirement.

One must be an approved and active TCADC, approved by the Board, prior to starting supervision and engaging in the

practice of alcohol and drug counseling. Supervision hours acquired under a Board-approved CADC supervisor will not

count towards the LCADC supervision requirement. Therefore, as a Temporary CADC working towards the LCADC,

please be sure you are under the correct type of supervision.

Where to find a list of Board-approved Supervisors: http://adc.ky.gov under “Quick Links”.

When you start supervision: It is best to document it on a regular basis. Keep good notes and maintain copies of

everything for your own records. You should begin to document your supervision on the verification of supervision

form found in the CADC application packet (Or LCADC packet if you are pursuing Licensure). Your hours will need to

be submitted on an annual basis (based on the issuance date of your TCADC) using this same form, along with the

“Supervision Annual Report” via your online eServices account.

Supervision sessions: Should not be documented as “blocks” of dates. List each session individually with the

corresponding date and time and the board-approved supervisor’s signatures.

If you have long supervision sessions: Document as much detail as possible as to what those sessions looked

like/the activities completed or it could cause your CADC/LCADC application to be deferred. Supervision sessions do

not “typically” last 3+ hours and should not be occurring every day. For information regarding the difference between

“work experience” and working alongside of your board-approved supervisor versus “clinical supervision”, please review

the laws and regulations booklet found at http://adc.ky.gov under “Resources”.

Classroom Training Hours: 1 academic credit hour equals 15 actual training hours. Therefore, if you took a 3 credit

hour course related to alcohol/drug counseling, it would equal 45 actual training hours.

The period of a temporary credential shall be terminated upon the passage of two years from

issuance. Upon receipt of an extension request cosigned by the board approved supervisor, the board may approve

no more than two, two-year extensions of the period of a temporary credential. Should you extension request not be

approved, you are welcome re-apply for the TCADC if you need more time.

Checklist: Temporary Certification as an Alcohol and Drug Counselor Page 3 of 5

This document is to only be used as a guide, not an interpretation of the law. To read the law in its entirety see Kentucky Revised Statutes KRS 309.080 to KRS 309.089 and Kentucky Administrative Regulations 201 KAR 35:010 to 201 KAR 35:090.

NEXT STEPS:

1. Print off and read through the Board’s Laws and Regulations Booklet found at http://adc.ky.gov

under “Resources”.

2. If approved, you will receive an approval letter sent to your home address, within approximately 2

weeks following the Board meeting. Your board-approved supervisor(s) of record will also receive a

carbon copy of your approval notification. Board meeting results will NOT be disclosed via phone or

email, you must wait for your letter to arrive. If you do not want to wait for the correspondence to

arrive via mail, you may try checking the board’s website the week following the board

meeting to see if you have been approved:

http://adc.ky.gov and click on “Verification” in the yellow bar across the top of the page to search

for your name or Direct link - http://oop.ky.gov/lic_search.aspx

If your name comes up and shows an active Temporary CADC with an issue and expiration date

– then you know you have been approved with the supervisor(s) of record you submitted along

with your application and can then call yourself a TCADC and count the hours of supervision

under your approved supervisor(s). If you do not see your name at all the week following the

board meeting, then please wait for your formal letter to arrive.

If you are not approved, you will receive a letter of explanation sent to your home address, within

approximately 2 weeks following the Board meeting. Board meeting results will NOT be disclosed via

phone or email, you must wait for your letter to arrive. You will most likely have an opportunity to

submit additional/missing information in time for the next monthly board meeting so your application

can be re-reviewed. Applicants that are not approved are NOT able work in the capacity of a

Temporary CADC, NOT able to call themselves a TCADC, and are NOT able to begin counting the

hours of supervision under the requested supervisor(s).

3. Print off the appropriate application packet and start recording your training and supervision on the

CERTIFICATION AS AN ALCOHOL AND DRUG COUNSELOR (CADC) APPLICATION. (Or, use

the LCADC application to record your hours if you are pursing Licensure instead of the CADC) found

at http://adc.ky.gov under “Resources” and “Applications and Forms”

4. Temporary CADC’s do not have Continuing Education Requirements while they are in the

temporary status, but rather TCADCs are expected to be working on the trainings, work hours,

and supervision hours needed for the CADC (or the LCADC).

5. Make sure to read the Board’s supervision regulation in full, found at http://adc.ky.gov by clicking on

“Resources” and “Kentucky Administrative Regulations” in the yellow bar across the top of the page

and select “201 KAR 35:070 Supervision Experience”.

Checklist: Temporary Certification as an Alcohol and Drug Counselor Page 4 of 5

This document is to only be used as a guide, not an interpretation of the law. To read the law in its entirety see Kentucky Revised Statutes KRS 309.080 to KRS 309.089 and Kentucky Administrative Regulations 201 KAR 35:010 to 201 KAR 35:090.

6. One year from the issuance of your temporary certification, YOU MUST SUBMIT A SUPERVISION

ANNUAL REPORT and YOUR SUPERVISION LOGS to the Board.

Annual Report Forms to Submit and Where to Locate the Forms:

The Supervision Logs/Form 13 Supervision Verification Form is located on the “Applications

and Forms” page at http://adc.ky.gov, under “Resources” at the top of the page.

The Annual Report/Form 14 Supervision Annual Report” is also located on the “Applications

and Forms” page at http://adc.ky.gov, under “Resources” at the top of the page.

Supervisees with annual reports due are to submit documentation via their eServices online

account found at http://adc.ky.gov by clicking on “Online Services – eServices” in the yellow bar

across the top of the page. Direct Link: https://oop.ky.gov/Eservices/Default.aspx

Once logged in, select the “Supervision” option on the main page.

You should see your board approved supervisor(s) listed.

Under your supervisor, you will first need to change the drop down box to “Annual Report” and

upload Form 14.

Then, change the drop down box to “Supervision Logs” and upload Form 13.

Supervisors may also upload the documentation for the supervisee, if they wish.

Should the Board request additional documentation, following the next regularly scheduled meeting

of the Board (or the following meeting), the supervisee should receive email correspondence

regarding their annual report stating the Board’s request for additional information. If the supervision

annual report is received and accepted, the supervisee will receive such approval email

correspondence.

ALL supervisees and supervisors should ensure their eServices online account (found at

http://adc.ky.gov by clicking on “Online Services – eServices” in the yellow bar across the top of the

page) is set up and updated with their correct contact information (including e-mail) so they may

receive important Board correspondence regarding supervision, etc.

It is a shared responsibility between supervisee and supervisor that the appropriate documentation

is submitted to the Board.

Direct Link: https://oop.ky.gov/Eservices/Default.aspx

7. Request to have two (2) Board-approved supervisors of record: If you would like two Board-

approved supervisors, an additional Supervisory Agreement (found in the Temporary CADC

application packet) shall be submitted to the Board for approval via your eServices online account.

201 KAR 35:070 states each supervisor of record shall provide supervision to the supervisee no less

than two (2) hours, two (2) times a month. 201 KAR 35:070 Section 7 states if a supervisee has

more than one (1) board-approved supervisor, the supervisors shall be in direct contact with each

other at least once every six (6) months, and they shall provide supervisory plans and reports to the

Checklist: Temporary Certification as an Alcohol and Drug Counselor Page 5 of 5

This document is to only be used as a guide, not an interpretation of the law. To read the law in its entirety see Kentucky Revised Statutes KRS 309.080 to KRS 309.089 and Kentucky Administrative Regulations 201 KAR 35:010 to 201 KAR 35:090.

board and copies to each other. A request to have two (2) supervisors at one (1) time shall require a

request to the board, which shall include detailed information as to how the supervisors shall

communicate and coordinate with each other in providing the required supervision.

8. Request to change or terminate your Board-approved supervisor: If you need to add, change, or

remove your supervisor(s) of record, these changes must be submitted via your online eServices

account. 201 KAR 35:070 Section 3(2) states upon a change of supervisor, a new plan for

supervision (Supervisory Agreement as found in the Temporary CADC application packet) shall be

submitted by the supervisor and supervisee to the board for approval (via their online eServices

account). Upon termination of the supervisor-supervisee relationship, the final report of supervision

(Supervision Evaluation and copies of Supervision Logs) shall be submitted to the board (via

their online eServices account) within thirty (30) days of the termination.

9. Begin preparing to take the IC&RC Alcohol and Drug Counselor written exam*. After you have

obtained the necessary work experience, supervision, and trainings necessary for the CADC, you

will then submit the CADC Application packet (found at http://adc.ky.gov by clicking on “Resources”

and “Applications and Forms”). When your application for CADC is approved, you will then be sent

instructions to register for the computer based exam.

EXAM PREPARATION, STUDY MATERIALS & PRACTICE EXAMS:

http://internationalcredentialing.org (ADC Exam)

*For those pursuing LCADC/LCADCA, you can prepare for the Licensure/Advanced Alcohol & Drug Counselor (AADC) exam.

You will not need to take both exams. EXAM PREPARATION, STUDY MATERIALS & PRACTICE EXAMS:

http://internationalcredentialing.org (AADC Exam)

Exam Information *NEW*

The Kentucky ADC Board has made the switch to computer based examinations. Applicants no longer have to wait

for the 4 specific written testing dates a year and no longer have to come to Frankfort. Applicants may take the

computer exam any time they can get scheduled at a location of their choosing. The computer examination content

is the same as the written examination content, and is still multiple choice. Whenever your CADC/LCADC application

is submitted and approved, you will then be given instructions on how to get registered for a computer testing

location and testing date of your own choosing – must be scheduled within 1 year from the date of approval.

10. It is your responsibility to keep the Board informed of any address, name, contact information,

employment, and/or supervisor changes. Changes can be submitted via your eServices online

account (found at http://adc.ky.gov by clicking on “Online Services – eServices” in the yellow bar

across the top of the page and click the RECORD CORRECTION or SUPERVISION option) Do not

rely on forwarding services of the United States Postal Service.

KBADC Form 1 Page 1 of 2

KENTUCKY BOARD OF ALCOHOL AND DRUG COUNSELORS

P.O. Box 1360, Frankfort, Kentucky 40602 ~ 911 Leawood Drive, Frankfort, Kentucky 40601 Phone (502) 782-8814 ~ http://adc.ky.gov

APPLICATION FOR: TEMPORARY REGISTRATION AS PEER SUPPORT SPECIALIST ( )

REGISTRATION AS PEER SUPPORT SPECIALIST ( )

TEMPORARY CERTIFICATION AS AN ALCOHOL AND DRUG COUNSLOR ( )

CERTIFICATION AS AN ALCOHOL AND DRUG COUNSLOR ( )

LICENSED CLINICAL ALCOHOL AND DRUG COUNSELOR ASSOCIATE ( )

LICENSED CLINICAL ALCOHOL AND DRUG COUNSELOR ( )

SECTION 1 – APPLICANT INFORMATION

1. ______________________________________________________________________________________ Name: First Middle Last Maiden

_____-______-__________________________________________________________________________ Social Security Number Date of Birth Home Phone Cell Phone

______________________________________________________________________________________ Mailing Address: Street City State Zip Code ______________________________________________________________________________________ Employer Business Phone ______________________________________________________________________________________ Employer’s Address: Street City State Zip Code ______________________________________________________________________________________ Home Email Business Email

2. Have you had a credential in Kentucky or any other state that has ever been suspended or revoked?

YES NO If yes, give details:

_______________________________________________________________________________________

3. Have you been convicted of a felony or plead guilty, including an Alford plea (other than minor traffic

violations) under the laws of the United States in the last 5 years? YES NO If yes, what offense?

__________________________________________________ (If yes, send supporting documentation.)

4. Are you credentialed as an Alcohol or Drug Counselor in any other state? YES NO

If yes, what state? _____________________________ Type of Credential? ________________________

5. Have you ever been discharged or forced to resign for misconduct or unsatisfactory service from any position

from any professional training program, or from the program of any university? YES NO

(If yes, send supporting documentation.)

6. Have you ever been sanctioned by the Kentucky Board of Alcohol and Drug Counselors or by any other

credentialing board or professional associations for ethical misconduct? YES NO

(If yes, send supporting documentation.)

7. Are you currently on active military duty? YES NO

KBADC Form 1 Page 2 of 2

SECTION 2 – APPLICANT EDUCATION

SECTION 3 – WORK EXPERIENCE (Attach Additional Related Experience If Needed)

School Name and Location Dates Attended Date of

Graduation Number of

Hours Degree

Obtained

High School/Equivalent

Baccalaureate

Master’s

Doctoral

Submit proof of your highest education achieved:

High school / equivalent - submit a copy of your diploma or certificate.

Other higher education - submit official transcript sent from registrar of the college or university.

Name of Employer: __________________________________________________________________

Title or Position: __________________________________________________________________

Employment Start Date: _____________________________ End Date: __________________________

Address of Employer: __________________________________________________________________

Clinical Supervisor: _______________________________ Credential Number: __________________

Total Number of Work Hours per Week Related to Alcohol and Drug Clients: ________________________

Describe Work Duties Related to Alcohol and Drug Clients: ______________________________________

____________________________________________________________ Name of Employer: __________________________________________________________________

Title or Position: __________________________________________________________________

Employment Start Date: _____________________________ End Date: __________________________

Address of Employer: __________________________________________________________________

Clinical Supervisor: _______________________________ Credential Number: __________________

Total Number of Work Hours per Week Related to Alcohol and Drug Clients: ________________________

Describe Work Duties Related to Alcohol and Drug Clients:______________________________________

_____________________________________________________________________________________

AFFIDAVIT

I do hereby certify under penalty of law, that the information contained herein is true, correct and complete to the best of my knowledge and belief. I am aware that, should an investigation at any time disclose such misrepresentation or falsification, my application could be rejected or my certification revoked by the Board. Furthermore, I agree to abide by the standards of practice and code of ethics approved by the Board.

____________________________________________________ ____________________________

Applicant’s Signature (Do not type or print) Date

KBADC Form 3 Page 1 of 3

KENTUCKY BOARD OF ALCOHOL AND DRUG COUNSELORS

P.O. Box 1360, Frankfort, Kentucky 40602 ~ 911 Leawood Drive, Frankfort, Kentucky 40601 Phone (502) 782-8814 ~ http://adc.ky.gov

SUPERVISORY AGREEMENT

To Be Completed By Applicant and Supervisor (Please Check One)

____Temporary Certification ____Licensed Associate

INSTRUCTIONS 1. Forms submitted without the appropriate signatures will be returned. 2. The completed form may be submitted to the Kentucky Board of Alcohol and Drug Counselors either by mail to

P.O. Box 1360, Frankfort, Kentucky 40602 or by delivery to 911 Leawood Drive, Frankfort, Kentucky 40601.

SECTION 1 APPLICANT INFORMATION

First Name Middle Name Last Name / / ( ) - ( ) -

Social Security Number Home Telephone Work Telephone

Email Address

Street Address

City

State Zip Code

SECTION 2 SUPERVISOR INFORMATION

First Name Middle Name Last Name

Email Address

Street Address

City State Zip Code ( ) -

Telephone Number Type of License/Certification Held and Number

/ / / /

Date of issue (Attach a copy) Expiration Date (Attach a copy)

Date of Board Approved Supervision Training (Attach copy of certificate of attendance)

Number of Supervisee’s Currently Providing with Board Approved Supervision

KBADC Form 3 Page 2 of 3

SECTION 3 INFORMATION RELATED TO SUPERVISED EXPERIENCE

Applicant Name _________________________________________ Name of organization or agency where experience will be gained (complete a separate form for each setting.)

Street Address of Organization or Agency

City State Zip Code Average number of hours expected to be gained per week:

Type of Setting: State/Government Agency Hospital Non-Profit DUI/Private Practice School Rehab Center

Type of peer support/counseling experience to be gained (check all that apply): Rehabilitation Center Judicial/Corrections Child & Adolescent Individual Counseling Adult Group Counseling Family Treatment Other

_________________________________ Describe

Describe specifically, and in detail, what work experience will be obtained to meet the criteria in the

following 12 core functions: (a) Screening; (b) Intake; (c) Client orientation; (d) Assessment; (e) Treatment

planning; (f) Counseling; (g) Case management; (h) Crisis intervention; (i) Client education; (j) Referral;

(k) Reports and recordkeeping; and (l) Consultation. (201 KAR 35:070)

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Describe specifically, and in detail, how supervision will focus on: (a) Screening; (b) Intake; (c) Client

orientation; (d) Assessment; (e) Treatment planning; (f) Counseling; (g) Case management; (h) Crisis

intervention; (i) Client education; (j) Referral; (k) Reports and recordkeeping; and (l) Consultation..(201

KAR 35:070)

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

KBADC Form 3 Page 3 of 3

I, as applicant, affirm that all information provided by me on this form is true and accurate and I affirm the following:

That I have read the board Law and Regulations related to supervised experience and that all supervised experience will be completed in accordance with board rules;

That I will meet with my supervisor at a minimum of 2 hours every 2 weeks of documented supervised experience;

That I will abide by all rules of the board, including ethics requirements;

That I understand the registration/temporary certification/clinical alcohol and drug counselor associate license is only valid while I practice under supervision;

That I notify the board if this supervisory arrangement is terminated; and

That I understand any additional supervisors and settings shall be approved by the board in advance.

Signature of Applicant Date

Printed Name This agreement shall not be effective until the board has issued the letter approving the agreement. I, as the board approved supervisor of the above named applicant, affirm that all information provided by me on this form is true and accurate and I affirm the following:

That all supervised experience will be completed in accordance with the Law and Regulations related to supervised experience and all subsequent board rules.

That I will provide supervision to the above name applicant at least 2 hours every 2 weeks of documented experience.

That I understand the full professional responsibility for services of the supervisee shall rest with the supervisor.

That I understand the supervisory arrangement is only valid while my credential remains in good standing.

That I will notify the board if the supervisory arrangement is terminated.

That I understand that I shall not serve as a supervisor of record for more than twelve persons obtaining experience for peer support/certification/licensure at the same time.

__________________________________________________ ____________

Signature of Supervisor Date

APPLICANT AND SUPERVISOR SHOULD KEEP A COPY OF THIS FORM FOR RECORDS

BOARD USE ONLY

Approved by ______ Date: __________________ Denied by ________ (Initials of Reviewer) (Initials of Reviewer)

_______________________________________________ Deferred by by ______ Date: __________________ _______________________________________________ (Initials of Reviewer) _______________________________________________ _______________________________________________